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neurogenic claudication

Clinical Disorders of the Aging Spine

Clinical Disorders of the Aging Spine

Teaser: 
Edward P Abraham, MD, FRCSC,
Associate Professor of Surgery, Department of Orthopaedics, Dalhousie University Medical School, Saint John Campus, Saint John NB Canada Canada East Spine Centre, Horizon Health Network.

Hamilton Hall, MD, FRCSC,
Professor, Department of Surgery, University of Toronto, Executive Director, Canadian Spine Society, Toronto, ON.

CLINICAL TOOLS

Abstract: In spite of the slightly increased incidence of infections, malignancies and systemic illnesses affecting the older spine, about 90% of back pain in the elderly, as in younger patients, is mechanical. This article covers several of the common problems: neurogenic claudication, degenerative disc disease, degenerative spondylolisthesis, disc herniation, spinal deformity and osteoporotic compression fractures. Treatment is both non-operative and surgical and the decisions about which to choose and therefore when to refer depend as much on the age and functional capacity of the patient as upon the specific pathology.
Key Words: neurogenic claudication, degenerative disc disease, degenerative spondylolisthesis, disc herniation, spinal deformity, osteoporotic fractures, imaging.

The diagnosis of neurogenic claudication is made on the history of intermittent leg dominant pain brought on by activity, usually walking, and relieved by rest in flexion, usually by sitting down. The physical examination while the patient is at rest is often normal.
Mechanical back pain associated with disc degeneration is seldom an indication for surgery and can usually be adequately managed through a combination of education, activity modification, general fitness and exercises selectively tailored to improve the pain-producing positons and movements.
Disc herniation producing acute sciatica is uncommon in the older patient and the diagnosis should be made with caution. True radicular pain is constant and leg dominant. Referred, intermittent leg pain frequently accompanies back dominant pain and should not be treated as sciatica.
Enduring spine surgery is a major challenge for the elderly patient. The decision to operate must be made after comprehensive consultation, emphasizing the prolonged recovery and weighing the potential benefits against the inevitable risks, including the risk to life.
Osteoporotic vertebral body compression fractures frequently occur without a recognized history of trauma. The pain, often in the thoracic or upper lumbar area, appears suddenly, is aggravated by movement (particularly bending forward) and is reduced but not eliminated by lying down. The acute phase can last several weeks but usually subsides without specific treatment. Multiple compression fractures over time will produce a kyphotic spine.
Back pain in the elderly should be managed with a minimum of medication. Mechanical pain can usually be controlled with the appropriate mechanical measures and additional analgesia is not required. Recourse to pain medication as a first line of treatment is not recommended and when employed should be limited to non-narcotic formulations. With the possible exceptions of acute sciatica and recent vertebral compression fractures, opioids should not be used.
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Disclaimer: 
This article was published as part of Managing the Health of Your Aging Patient: Therapies that Could Help Improve Quality of Life eCME resource. The development of Managing the Health of Your Aging Patient: Therapies that Could Help Improve Quality of Life eCME resource was supported by an educational grant from Medtronic Canada.

Managing Leg Dominant Pain

Managing Leg Dominant Pain

Teaser: 

Yoga Raja Rampersaud, MD, FRCSC,1 Julia Alleyne, BHSc(PT), MD, CCFP, Dip. Sport Med MScCH,2 Hamilton Hall, MD, FRCSC,3

1Associate Professor Department of Surgery, University of Toronto, Divisions of Orthopaedic and Neurosurgery, University Health Network Medical Director, Back and Neck Specialty Program, Altum Health, Immediate Past President Canadian Spine Society, Toronto, ON.
2Associate Professor, Department of Family and Community Medicine, University of Toronto, Medical Director, Sport CARE, Women’s College Hospital, Toronto, ON.
3Professor, Department of Surgery, University of Toronto; Medical Director, Canadian Back Institute; Executive Director, Canadian Spine Society, Toronto, ON.

CLINICAL TOOLS

Abstract: Leg dominant pain suggests direct nerve root involvement: radicular, not referred symptoms. Constant pain associated with positive neurological findings usually results from an acute disc herniation. Symptoms are the result of mechanical compression but principally reflect an inflammatory response, properly designated sciatica. Intermittent leg dominant pain triggered by activity in extension and relieved by rest in flexion probably represents neurogenic claudication: nerve root ischemia secondary to spinal stenosis. Except for acute cauda equina syndrome, acute sciatica is initially managed with scheduled rest, adequate medication, and time. Non-responsive cases may require surgery. Surgery also shows superior outcomes for disabling neurogenic claudication.
Key Words:leg dominant pain, sciatica, neurogenic claudication, cauda equina syndrome, surgery.

HealthPlexus is offering an eCME in support of the Back Pain Management Resource

eCME: The Latest in Back Pain Management

This CME activity offers interactive Videos, Animations, Pre- and Post-test Quizzes and you will be able to download a Certificate of Participation upon completion.

True spine-generated, leg dominant pain is consistently reproduced by particular spinal movements or positions.
No imaging investigation is required for a patient presenting an unequivocal clinical picture and exhibiting steady predictable improvement.
Of the four back pain syndromes, only neurogenic claudication is consistently best treated by surgery.
In contrast to the back dominant cases, in sciatica there is a definite role for short-acting narcotics or psychotropic drugs for uncontrolled pain.
Criteria for Surgical Referral
Emergency Referral The symptoms of Cauda Equina Syndrome are: - Urinary retention followed by insensible urinary overflow. - Unrecognized fecal incontinence. - Loss or decrease in saddle/perineal sensation. Acute Cauda Equina Syndrome is a surgical emergency.
Consider Elective Referral Failure to respond to a trial of conservative care: - Unbearable constant leg dominant pain. - Worsening nerve irritation tests (SLR or femoral nerve stretch). - Expanding motor, sensory or reflex deficits. - Recurrent disabling sciatica. - Disabling neurogenic claudication.
To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is only $20 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.

Lumbar Spinal Stenosis: Evidence for Treatment

Lumbar Spinal Stenosis: Evidence for Treatment

Teaser: 


David L. Snyder, PhD, Senior Research Analyst, Evidence-Based Practice Center, ECRI, Plymouth Meeting, PA, USA.
David Doggett, PhD, Senior Research Analyst, Evidence-Based Practice Center, ECRI, Plymouth Meeting, PA, USA.
Charles Turkelson, PhD, Chief Research Analyst and Director, Evidence-Based Practice Center, ECRI, Plymouth Meeting, PA, USA.

Degenerative lumbar spinal stenosis is a common problem among older adults. Stenotic compression of spinal nerves can result in low back pain, disabling leg pain, and greatly restricted walking capacity. Conservative therapies are usually prescribed for mild symptoms and surgery is prescribed for severe symptoms, while patients with moderate symptoms may not have an obvious treatment choice. The clinical evidence supporting these treatment options has been criticized because of problems with study design and quality that complicate their assessment. Despite the poor quality of most of the literature, recent studies provide better information and a means of starting to judge the effectiveness of treatment.

Key words: lumbar spinal stenosis, neurogenic claudication, conservative therapy, surgical intervention.